l25 l 1832 Robert Lewins 1855 Sidney Ringer 8 mg NaCl, 0,3 g KCl, 0,33 g CaCl 1l di H 2 O Alexis Hartmann 1941 Albumina ElettrolitiECF / ICF ECF mEq/l Fabbisogno mEq/k/d NaECF KICF3.1 1.5 Mg ICF 0.85 20 Ca ECF 2 PO 4 3- ICF2.7 40 ClECF H 2 OECF/ICF20 30 ml/d I cristalloidi sono soluzioni che contengono soluti di peso molecolare inferiore ai 30 kDa : generalmente sali o glucosio. Essi passano con facilit attraverso la membrana dei capillari. Possono essere isotonici,ipotonici o ipertonici. SolutionOsmolalityPhNa + K + HCO3Cl Plasma ,9% Saline % Saline % Saline Ringer Lactate Ringer Acetate Plasmalyte A % glucose D5W HES solutions are produced by hydroxyethyl substitution of amylopectin obtained from sorghum, maize, or potatoes. A high degree of substitution on glucose molecules protects against hydrolysis by non specific amylases in the blood, thereby prolonging intravascular expansion, but this action increases the potential for HES to accumulate in reticuloendothelial tissues, such as skin (resulting in pruritus), liver, and kidney. Succinylated gelatin, urea linked gelatin Dextran solutions. I colloidi sono soluzioni di molecole ad elevato peso molecolare che passano con difficolt lendotelio. Linteresse nei loro confronti legato alla maggiore efficacia come effetto volume oltre che ad interessanti propiet reologiche ed antiinfiammatorie.Comunque, in ampi studi randomizzati,i colloidi non si sono dimostarti superiori in termini di misuredi outcome di elevato profilo come la mortalit. Solution Osmolality (mOsm) Na + (mM) Mw (kDa) Initial volume expansion (%) Plasma half life (Hr) / dosage limit Plasma295140VaryingLow Albumin 4%,5% 24;no limit Albumin 20%,25% 24;no limit Hespan 6 in ns ml/Kg/die Hestend 6% in lactate electrolite solution hr;20 ml/kg/d Voluven6% in ns :1 50 ml/Kg/die Volulyte 6% in balanced salt solution :1 50 ml/Kg/die Gelofusin 4% in ns :1No upper limits Rheomacrodex 10% Dextran 40 in ns gr/kg/die Macrodex 6% Dextran 70 in ns gr/kg/die HES solutions (10%) with a molecular weight of more than 200 kD and a molar substitution ratio of more than 0.5 with a molecular weight of 130 kD and molar substitution ratios of 0.38 to HES is 33 to 50 ml per kilogram of body weight per day. HES solutions (6%) I GenerazioneIII GenerazioneII GenerazioneIV Generazione 450/0.7 HMW/HMS 70/ / / / /0.42 Balanced 130/0.42 HetastarchPentastarch Tetrastarch Voluven Venofundin Tetraspan The observed ratio of HES to crystalloid in these trials was approximately 1:1.3, which is consistent with the ratio of albumin to saline reported in the SAFE study. The selection and use of resuscitation fluids is based on physiological principles, but clinical practice is determined largely by clinician preference, with marked regional variation. Despite what may be inferred from physiological principles, colloid solutions do not offer substantive advantages over crystalloid solutions with respect to hemodynamic effects. Although albumin has been determined to be safe for use as a resuscitation fluid in most critically ill patients and may have a role in early sepsis, its use is associated with increased mortality among patients with traumatic brain injury. The use of hydroxyethyl starch (HES) solutions is associated with increased rates of renal-replacement therapy and adverse events among patients in the intensive care unit (ICU). There is no evidence to recommend the use of other semisynthetic colloid solutions. Balanced salt solutions are pragmatic initial resuscitation fluids, although there is little direct evidence regarding their comparative safety and efficacy. The use of normal saline has been associated with the development of metabolic acidosis and acute kidney injury. The safety of hypertonic solutions has not been established. All resuscitation fluids can contribute to the formation of interstitial edema, particularly under inflammatory conditions in which resuscitation fluids are used excessively. Critical care physicians should consider the use of resuscitation fluids as they would the use of any other intravenous drug. Although the use of resuscitation fluids is one of the most common interventions in medicine, no currently available resuscitation fluid can be considered to be ideal. Selection, timing, and doses of intravenous fluids should be evaluated as carefully as they are in the case of any other intravenous drug, with the aim of maximizing efficacy and minimizing iatrogenic toxicity. Chloride is implicated in impaired renal function with hyperchloraemia resulting in less natiuresis than might be expected after saline infusion. Chloride may influence the renal vasculature. There is also some evidence that renin secretion is mediated by chloride. Hyperchloraemia may also influence coagulation. Thromboelastography indicates more effects on coagulation and platelet function with saline when compared with a balanced salt solution In summary: - hyperchloraemic acidosis is seen with the use of large volumes of saline and is almost certainly due to the chloride load; - there appear to be some side-effects associated with saline use, but to date these have not translated into clinically important outcomes, though this may be through lack of data. Is usually the result of sodium bicarbonate infusion for metabolic acidosis,or aggressive use of hyprtonic saline to treat intracranial pressure. When renal sodium excretion is impaired it may be necessary to increase it with a diuretic. Because the urinary sodium concentration during furosemide (~ 80 mEq/l) is less than plasma sodium concentration, diuresis can aggravate the hypernatremia. Lactate clearance = LactateED Presentation - LactateHour 6 100 LactateED Presentation Associations between increased cumulative positive fluid balance and long-term adverse outcomes have been reported in patients with sepsis. In trials of liberal versus goal-directed or restrictive fluid strategies in patients with the acute respiratory distress syndrome (particularly in perioperative patients), restrictive fluid strategies were associated with reduced morbidity. However, since there is no consensus on the definition of these strategies, high-quality trials in specific patient populations are required. Recently advocated approaches include waiting until the rate of drainage is less than 100 mL, less than 150 mL less than 2 mL/kg body weight, less than 200mL, less than 300 mL, or less than 400mL per 24 hours, or essentially ignoring the rate of drainage. Since properly functioning, non occluded chest tubes typically produce some fluid, it is unusual to wait until there is no drainage to remove tubes, although this approach has also been described Pleural fluid/kg body weight : 0.13 0.06 mL 5 to 35 m Production and reabsorption : 0.01 to 0.02 mL / kg / h Microvascular filtrate. Protein content : approx. 1 g/dL Ann Thorac Surg 2013;96:22627 Pleural fluid layer Pleural surface area of both hemithoraces : 4,000 cm 2 Visceral and parietal pleural layers 30 to 40 m Because of this increased rate of absorption, a 10- fold increase in the rate of fluid production results in only a 15% to 20% increase in steady-state pleural fluid volume. In addition to increased pleural fluid volume/pressure, stimulation of 2 -adrenergic and 2 -adrenergic receptors appears to increase lymphatic drainage from the pleural space in rabbits. A 70-kg adult normally should be able to reabsorb 470 mL of pleural fluid per day from each hemithorax. Two studies of patients with clinically apparent pleural effusions estimated the rate of reabsorption as 0.11 and 0.36 mL/ kg /h In summary, judging from the variety of approaches described in the literature and available data bearing on the safety of these approaches, there appears to be no consensus as to the rate of drainage that should be used as a threshold for tube removal and no evidence to suggest that it is unsafe to remove tubes that still have a relatively high rate of fluid drainage. To help resolve this question, a non inferiority randomized trial is currently examining patient- centered outcomes to assess the safety of removal of chest tubes independent of the rate of drainage relative to a 2 mL/kg body weight per day threshold. Ann Thorac Surg 2013;96:22627 2000 pts Sottoposti a resezione polmonare in elezione 199 ( 3,8%) leak persistente 194,dimessi a casa ritornano a controllo a 16 gg